Improving health/reducing risk

Because of the government-funded research I led at Massachusetts General Hospital and Harvard Medical School on middle-schoolers and violent video games, I received many emails and phone calls after the horrific murders at Sandy Hook Elementary in Newtown, CT. I also had the privilege of meeting Vice President Biden and talking with him about my research and its implications for policy.

Here are some links to recent media interviews about violent video games and their potential connection to real-world violence:

As a public health booster, you’d expect me to like the new Jamie Oliver reality show on ABC. The young British chef parachutes into a West Virginia town that boasts a frighteningly high obesity rate. There’s a new nutrition sheriff in town who’s gonna clean up this place–er, put healthful food on their school lunch plates.

I do believe he truly wants to help. And it’s clear as plastic wrap that cheap, over-processed food is setting up many of these children for premature death. But although Jamie’s food may be fresh, his “I know best” paternalistic attitude is a counterproductive retread. Here are several of his behavior-change blind spots:

Other people should like what I like.

In part of the program, Jamie provided a family with a week’s worth of healthy meal recipes and ingredients, including an array of unfamiliar herbs. He seemed perturbed that, at the end of the week, most of the exotic ingredients sat wilting in the back of their fridge. Why not instead ask the family about their favorite dishes, and provide recipes that take those preferences into account, but nudge them in a healthier direction?

None of us likes to make drastic changes. And if one meal turns out subpar, it’s easy to reject the new approach wholesale. This is especially true for children, who are not only picky about strange textures and smells, but are often more sensitive to bitter tastes. You may need to offer a new food a dozen times or more before a child will try it.

Other people have the same priorities I do.

Jamie was appalled when, after blending and straining a chicken carcass into beige glop, kids were willing to eat the glop if breaded and fried into patties. When he did this demonstration for kids in the U.K., they always backed away.

I had two thoughts: First, hasn’t he ever watched those gross-out kids’ shows (e.g., Nickelodeon’s famous slime), or seen the deliberately disgusting candy some kids like? He doesn’t seem to know a lot about normal child development.

Second, when he asked the kids why they would eat that fried glop, they simply said, “Because I’m hungry.” A not-insignificant number of these kids probably come from food-insecure homes, where they’d better eat while they can in case the cupboard’s bare tomorrow.

If they’re too dumb to get it, add some cartoons.

In a desperate effort to make vegetables appealing, Jamie parades through the school in a peapod costume. This reminds me of “math-made-easy” books that stuff in cartoons and jokes in lieu of a better instructional approach. Kids are smart. If vegetables are so great, why the hard sell?

Scare ‘em straight.

After failing to get the family to cook healthier meals, Jamie shepherds them to a pediatrician. A physical exam and tests reveal that the son is on a fast track to Type 2 diabetes. Everyone is understandably and appropriately upset.

But what are they supposed to do about it? Research shows that unless a “fear appeal” is strongly linked to specific actions that will reduce risk, people will “cope” through denial. They also need the ability and know-how to take action, and belief in their own power to change.

To his credit, Jamie spends some time cooking with the son, showing him how to whip up a healthy chicken stir-fry. But that’s a small step on a long journey.

The other day, I heard an NPR health podcast titled “Bad Habits Die Hard–Will We Die With Them?” It includes an interview with Charlotte Schoenborn, a CDC statistician, who notes ruefully that after years of health education campaigns, there’s relatively little to show for these efforts: “It’s amazing how hard it is to change these personal health behaviors.”

One problem is disagreement about what should be changed. For example, the NPR report noted with disapproval that more educated people are more likely to drink alcohol, with the unstated assumption that all drinking is bad. A slew of health reports suggest that for most adults over 30, the benefits of a drink a day may outweigh the risks. There is also concern about New York City’s campaign to reduce salt intake across the board, which some view as tantamount to an uncontrolled experiment with the public’s health.

One area of agreement is that children’s eating habits are decidedly subpar. Experts talk of an epidemic of high blood pressure, Type 2 diabetes, sleep apnea and even knee problems in increasingly heavy kids and teens. To cut these risks, the NPR podcast mentioned the idea of an “in your face” campaign to reduce obesity, akin to past antismoking campaigns.

Wait a minute. I’ve done work in both smoking prevention/cessation and weight loss, and I worry that this attitude and approach could do more harm than good.

First, there’s zero evidence that shaming fat people helps them lose weight, whereas there’s lots of evidence that stress promotes weight gain (even without overeating), and that accepting obesity as shameful legitimizes weight discrimination – which appears to harm health as well as undermine access to good medical care.

I’m a fan of starting with low-risk, low-hassle, pretty-good-payoff interventions. On the issue of healthy eating, we can take a lesson from financial psychology. We know that employees save more with opt-out company retirement plans–ones that automatically set aside part of your monthly paycheck, unless you actively stop it. Economists sing the praises of setting up smart default options, then letting inertia work on the side of the angels.

There are already efforts underway to put healthy food choices in front of kids’ faces at school. We can also work to change the defaults in our kitchens at home. Leave healthy snacks (but only things your kids like, such as bananas) right up front on the counter. Position those little cups of fruit in juice, or some not-overly-sugary yogurt, so it hits your child’s eye first when she opens the fridge. Make inertia your friend.